Sir, I was very interested to read D. Howarth's letter discussing the problems of implants and dementia (BDJ 2013; 214: 47). I completely agree that older people are a dental time bomb and that oral hygiene in residential care homes is often suboptimal to say the least, but I cannot agree that this is likely to cause more problems for patients with dental implants than it is for those without. Oral hygiene is equally important for patients with or without dental implants as is attention to diet. But in my experience peri-implant infection is much less common than periodontal disease, and significantly implants do not suffer from root caries which is a large part of the problem of the ageing dentition and which is why your correspondent is seeing teeth decayed to roots around sound implant supported restorations. The logical conclusion is to provide more implant supported restorations not fewer.

I am unsure as to what D. Howarth is referring when he writes of restorative jewellery but I presume he is implying that dental implants are provided for cosmetic reasons. Virtually all dentistry has an aesthetic component but in my experience many more implants are placed for functional reasons than for purely aesthetic reasons. I am sure no dentist would deprive a patient of the huge benefits, possibly over many years, of implants used to retain full lower dentures, which have no aesthetic value at all. Even in a case with a high aesthetic component, such as replacement of a single central incisor, it is difficult to imagine persuading a 20-year-old that the advantages of implant replacement over the alternatives are outweighed by the prospect of possible maintenance difficulties 60 years or more in the future.

Many elderly patients will present in the future with not just implant supported restorations but also complex tooth supported restorations and the oral care for either should be very similar. The treatment planning for these patients earlier in life should include both where appropriate.

The answer to the problem is not to use fewer implants but to lobby for better oral care for the elderly and to try to preserve both natural and restored dentition whether implant or tooth supported. The only alternative is to resort to full clearances and full dentures which I am sure no dentist would like to see again.

1. Southport